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Alencar de Pinho N, Prezelin-Reydit M, Harambat J, Couchoud C, Glaudet F, Combe C, Rondeau V, Leffondré K. Arteriovenous access creation and hazards of hospitalization and death in patients starting hemodialysis. Nephrol Dial Transplant 2024; 39:978-988. [PMID: 38012126 DOI: 10.1093/ndt/gfad251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Recent evidence suggests an overestimation of the benefits associated with arteriovenous (AV) fistula versus graft in certain populations. We assessed hazards of all-cause and cause-specific hospitalization and death associated with AV access type in patients who started hemodialysis with a catheter in France, overall and by subgroups of age, sex and comorbidities. METHODS We performed a target trial emulation including patients who initiated hemodialysis with a catheter from 2010 through 2018 and were followed by the REIN Registry. We identified first-created fistula or graft through the French national health-administrative database. We used joint frailty models to deal with recurrent hospitalizations and potential informative censoring by death, and inverse probability weighting to account for confounding. RESULTS From the 18 800 patients included (mean age 68 ± 15 years, 35% women), 5% underwent AV graft creation first. The weighted hazard ratio (wHR) of all-cause hospitalization associated with graft was 1.08 [95% confidence interval (CI) 1.02 to 1.15], that of vascular access-related hospitalization was 1.43 (95% CI 1.32 to 1.55), and those of cardiovascular- and infection-related hospitalizations were 1.14 (95% CI 1.03 to 1.26) and 1.11 (95% CI 0.97 to 1.28), respectively. Results were consistent for most subgroups, except that the highest hazard of all-cause, cardiovascular- and infection-related hospitalizations with graft was blunted in patients with comorbidities (i.e. diabetes, wHR 1.01, 95% CI 0.93 to 1.10; 1.10, 95% CI 0.96 to 1.26; and 0.94, 95% CI 0.78 to 1.12, respectively). CONCLUSIONS In patients starting hemodialysis with a catheter, AV graft creation is associated with increased hazard of vascular access-related hospitalizations compared with fistula. This may not be the case for death or other causes of hospitalization.
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Affiliation(s)
- Natalia Alencar de Pinho
- Université de Bordeaux, INSERM, Bordeaux Population Health Research Center, UMR1219, CIC1401-EC, Bordeaux, France
| | - Mathilde Prezelin-Reydit
- Université de Bordeaux, INSERM, Bordeaux Population Health Research Center, UMR1219, CIC1401-EC, Bordeaux, France
- Maison du Rein - AURAD Aquitaine, Gradignan, France
- INSERM, Clinical Investigation Center-Clinical Epidemiology-CIC-1401, Bordeaux, France
| | - Jerome Harambat
- Université de Bordeaux, INSERM, Bordeaux Population Health Research Center, UMR1219, CIC1401-EC, Bordeaux, France
- INSERM, Clinical Investigation Center-Clinical Epidemiology-CIC-1401, Bordeaux, France
- Department of Pediatric Nephrology, CHU de Bordeaux, Bordeaux, France
| | - Cécile Couchoud
- Registre REIN, Agence de la biomédecine, Saint Denis La Plaine, France
| | - Florence Glaudet
- Cellule régionale REIN Limousin, Department of Nephrology, CHU Dupuytren 2, Limoges, France
| | - Christian Combe
- INSERM, Clinical Investigation Center-Clinical Epidemiology-CIC-1401, Bordeaux, France
- Department of Nephrology Transplantation Dialysis and Apheresis, CHU de Bordeaux, Univ. Bordeaux, Bordeaux, France
- Université de Bordeaux, Inserm U1026, Bordeaux, France
| | - Virginie Rondeau
- Université de Bordeaux, INSERM, Bordeaux Population Health Research Center, UMR1219, CIC1401-EC, Bordeaux, France
| | - Karen Leffondré
- Université de Bordeaux, INSERM, Bordeaux Population Health Research Center, UMR1219, CIC1401-EC, Bordeaux, France
- INSERM, Clinical Investigation Center-Clinical Epidemiology-CIC-1401, Bordeaux, France
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Kanbay M, Basile C, Battaglia Y, Mantovani A, Yavuz F, Pizzarelli F, Luyckx VA, Covic A, Liakopoulos V, Mitra S. Shared decision making in elderly patients with kidney failure. Nephrol Dial Transplant 2024; 39:742-751. [PMID: 37742209 PMCID: PMC11045282 DOI: 10.1093/ndt/gfad211] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Indexed: 09/26/2023] Open
Abstract
'Elderly' is most commonly defined as an individual aged 65 years or older. However, this definition fails to account for the differences in genetics, lifestyle and overall health that contribute to significant heterogeneity among the elderly beyond chronological age. As the world population continues to age, the prevalence of chronic diseases, including chronic kidney disease (CKD), is increasing and CKD frequently progresses to kidney failure. Moreover, frailty represents a multidimensional clinical entity highly prevalent in this population, which needs to be adequately assessed to inform and support medical decisions. Selecting the optimal treatment pathway for the elderly and frail kidney failure population, be it haemodialysis, peritoneal dialysis or conservative kidney management, is complex because of the presence of comorbidities associated with low survival rates and impaired quality of life. Management of these patients should involve a multidisciplinary approach including doctors from various specialties, nurses, psychologists, dieticians and physiotherapists. Studies are mostly retrospective and observational, lacking adjustment for confounders or addressing selection and indication biases, making it difficult to use these data to guide treatment decisions. Throughout this review we discuss the difficulty of making a one-size-fits-all recommendation for the clinical needs of older patients with kidney failure. We advocate that a research agenda for optimization of the critical issues we present in this review be implemented. We recommend prospective studies that address these issues, and systematic reviews incorporating the complementary evidence of both observational and interventional studies. Furthermore, we strongly support a shared decision-making process matching evidence with patient preferences to ensure that individualized choices are made regarding dialysis vs conservative kidney management, dialysis modality and optimal vascular access.
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Affiliation(s)
- Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Carlo Basile
- Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
| | - Yuri Battaglia
- Department of Medicine, University of Verona, Verona, Italy
- Nephrology and Dialysis Unit, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Alessandro Mantovani
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Furkan Yavuz
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | | | - Valerie A Luyckx
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Paediatrics and Child Health, University of Cape Town, South Africa
- Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center – ‘C.I. Parhon’ University Hospital, and ‘Grigore T. Popa’ University of Medicine, Iasi, Romania
| | - Vassilios Liakopoulos
- Second Department of Nephrology, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sandip Mitra
- Manchester Academy of Health Sciences Centre (MAHSC), Manchester University Hospitals and University of Manchester, Manchester, UK
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Kingsmore DB, Edgar B, Aitken E, Calder F, Franchin M, Geddes C, Inston N, Jackson A, Jones RG, Karydis N, Kasthuri R, Mestres G, Papadakis G, Sivaprakasam R, Stephens M, Stevenson K, Stove C, Szabo L, Thomson PC, Tozzi M, White RD. Quality assurance in surgical trials of arteriovenous grafts for haemodialysis: A systematic review, a narrative exploration and expert recommendations. J Vasc Access 2024:11297298241236521. [PMID: 38501338 DOI: 10.1177/11297298241236521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Introducing new procedures and challenging established paradigms requires well-designed randomised controlled trials (RCT). However, RCT in surgery present unique challenges with much of treatment tailored to the individual patient circumstances, refined by experience and limited by organisational factors. There has been considerable debate over the outcomes of arteriovenous grafts (AVG) compared to AVF, but any differences may reflect differing practice and potential variability. It is essential, therefore, when considering an RCT of a novel surgical procedure or device that quality assurance (QA) is defined for both the new approach and the comparator. The aim of this systematic review was to evaluate the QA standards performed in RCT of AVG using a multi-national, multi-disciplinary approach and propose an approach for future RCT. METHOD The methods of this have been previously registered (PROSPERO: CRD420234284280) and published. In summary, a four-stage review was performed: identification of RCT of AVG, initial review, multidisciplinary appraisal of QA methods and reconciliation. QA measures were sought in four areas - generic, credentialing, standardisation and monitoring, with data abstracted by a multi-national, multi-speciality review body. RESULTS QA in RCT involving AVG in all four domains is highly variable, often sub-optimally described and has not improved over the past three decades. Few RCT established or defined a pre-RCT level of experience, none documented a pre-trial education programme, or had minimal standards of peri-operative management, no study had a defined pre-trial monitoring programme, and none assessed technical performance. CONCLUSION QA in RCT is a relatively new area that is expanding to ensure evidence is reliable and reproducible. This review demonstrates that QA has not previously been detailed, but can be measured in surgical RCT of vascular access, and that a four-domain approach can easily be implemented into future RCT.
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Affiliation(s)
- David B Kingsmore
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Ben Edgar
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Emma Aitken
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Francis Calder
- Renal & Transplant Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Marco Franchin
- Department of Vascular Surgery, University of Insubria, Varesi, Italy
| | - Colin Geddes
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nick Inston
- Renal and Transplant Surgery, University Hospital Birmingham, Birmingham, UK
| | - Andrew Jackson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Rob G Jones
- Interventional Radiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Nikolaos Karydis
- Department of Renal and Transplant Surgery, University of Athens, Athens, Greece
| | - Ram Kasthuri
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Gaspar Mestres
- Department of Vascular Surgery, University of Barcelona, Barcelona, Spain
| | - Georgios Papadakis
- Renal & Transplant Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Mike Stephens
- Dialysis Access Team, University Hospital of Wales, Cardiff, UK
| | - Karen Stevenson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Callum Stove
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Lazslo Szabo
- Dialysis Access Team, University Hospital of Wales, Cardiff, UK
| | - Peter C Thomson
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Matteo Tozzi
- Department of Vascular Surgery, University of Insubria, Varesi, Italy
| | - Richard D White
- Department of Interventional Radiology, University Hospital of Wales, Cardiff, UK
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Murea M, Allon M. The reasons for comparative effectiveness clinical trials of arteriovenous fistula versus graft strategy in older adults on hemodialysis with a catheter. Clin Nephrol 2023; 100:243-248. [PMID: 37877300 PMCID: PMC10795491 DOI: 10.5414/cn111227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 11/09/2023] [Indexed: 10/26/2023] Open
Abstract
Clinicians and patients are guided by observational studies to make one of the most consequential decisions for patients with advanced kidney disease: the selection of the "right" hemodialysis vascular access. More than a decade ago, a call for randomized clinical trials was made to equitably compare clinical outcomes between arteriovenous (AV) fistulas (AVFs) and AV grafts (AVGs). Mounting evidence suggests that trade-offs between AVF- and AVGrelated outcomes are context dependent. In this article, we summarize four streams of evidence that collectively underpin the burden of equipoise between the two types of AV access in older adults with comorbidities who are on hemodialysis with a central venous catheter.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, and
| | - Michael Allon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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